The updating of clinical practice guidelines: insights from an international survey

BACKGROUND: Clinical practice guidelines (CPGs) have become increasingly popular, and the methodology to develop guidelines has evolved enormously. However, little attention has been given to the updating process, in contrast to the appraisal of the available literature. We conducted an international survey to identify current practices in CPG updating and explored the need to standardize and improve the methods. METHODS: We developed a questionnaire (28 items) based on a review of the existing literature about guideline updating and expert comments. We carried out the survey between March and July 2009, and it was sent by email to 106 institutions: 69 members of the Guidelines International Network who declared that they developed CPGs; 30 institutions included in the U.S. National Guideline Clearinghouse database that published more than 20 CPGs; and 7 institutions selected by an expert committee. RESULTS: Forty-four institutions answered the questionnaire (42% response rate). In the final analysis, 39 completed questionnaires were included. Thirty-six institutions (92%) reported that they update their guidelines. Thirty-one institutions (86%) have a formal procedure for updating their guidelines, and 19 (53%) have a formal procedure for deciding when a guideline becomes out of date. Institutions describe the process as moderately rigorous (36%) or acknowledge that it could certainly be more rigorous (36%). Twenty-two institutions (61%) alert guideline users on their website when a guideline is older than three to five years or when there is a risk of being outdated. Twenty-five institutions (64%) support the concept of "living guidelines," which are continuously monitored and updated. Eighteen institutions (46%) have plans to design a protocol to improve their guideline-updating process, and 21 (54%) are willing to share resources with other organizations. CONCLUSIONS: Our study is the first to describe the process of updating CPGs among prominent guideline institutions across the world, providing a comprehensive picture of guideline updating. There is an urgent need to develop rigorous international standards for this process and to minimize duplication of effort internationally

Tratamiento conservador del cáncer de mama: valoración de los resultados

Introducción: La asociación de cirugía limitada y radioterapia es el tratamiento de elección para un gran número de mujeres con cáncer de mama; no obstante esta opción terapéutica va asociada a un número no despreciable de recidivas sobre la mama tratada (1-1,5% por año de seguimiento). Material y Métodos: Se analizan 641 casos de mujeres con cáncer de mama, tratados mediante cirugía conservadora de la mama y radioterapia y seguidos durante una media de 50 meses. La técnica consistió preferentemente en la practica de una Resección Segmentaria de mama con vaciamiento axilar, al menos de los niveles I y II (excepto en los CIS a partir de 1997), complementada con la administración de Radioterapia (45-50 Gy sobre la mama y una sobreimpresión de 15-20 Gy). Resultados: La edad media fue de 52.3 años, con extremos en 21 y 82 años El tamaño medio tumoral fue pT: 1,7 cm y el 63,1% de los casos correspondieron a tumores pT1. En 41 casos no se realizó vaciamiento axilar (35 CIS y 6 pT1mic). En 4 casos existió afectación puntual de bordes (componente intraductal) que fueron sometidos a sobreimpresión radioterápica con 20Gy. Tras un seguimiento medio de 50 meses, el 91,4% están libres de enfermedad y en 12 casos (1,9%) se desconocía su estado. Se han producido 13 recidivas (2%) a nivel mamario (2 de ellas en un cuadrante distinto). Conclusiones: El estado de los bordes de resección en un factor fundamental en la cirugía conservadora del cáncer de mama. La resección del tumor debe ser suficientemente amplia e incluir el segmento mamario asiento del tumor, para asegurar un alto índice de control local, sin comprometer el resultado cosmético. El estudio histológico de los bordes de resección permite reducir significativamente la necesidad de una segunda cirugía.Introduction: Conservative surgery combined with radiotherapy is an effective treatment in many cases of breast cancer. Nevertheless this therapy is associated with a not inconsiderable number of recurrences in the remaining breast after excision (1-1.5% recurrences per year of follow-up). Material and Methods: We reviewed 641 cases of breast cancer (age average was 52.3 years (21-82) and tumour size average 1.7 cm, 3% corresponded to pT1 tumours) treated with conservative surgery combined with radiotherapy, average follow-up of 50 months. The technique consisted of segmentectomy and at least level I-II axilary dissection (excluding in situ carcinoma diagnosed since 1997, in which lymphadenectomy was not performed). Adjuvant radiotherapy was also indicated (giving a dose of 45-50 Gy to the breast, and another 15-20 Gy dose was given to tumour size). Results: In 41 cases lymphadenectomy was not performed (35 cases of Tis, and 6 pTmic). In 4 cases, 20 Gy radiotherapy was administered to the tumour excision site because of in situ carcinoma disease in the margins. During follow-up of 50 months, 91.4% of the patients were disease- free; in 12 cases we are not informed of the present status. 13 recurrences (2%) have been found, two of which were in a different quadrant. Conclusions: The status of the surgical margins is an important factor in the practice of conservative surgery. Tumour excision must be broad enough and must include the whole segment in which the tumour is located to obtain local control of the disease, maintaining an acceptable cosmetic appearance. The intraoperative study of specimen margins permits the reduction of cases in which a second operation is needed

Attitudes and perceptions about clinical guidelines: a qualitative study with Spanish physicians

Estudio cuyo objetivo es la evaluación de las actitudes y percepciones los médicos españoles con relación las Guías de práctica clínica. Spanish physicians towards CGs

The updating of clinical practice guidelines: insights from an international survey

BACKGROUND: Clinical practice guidelines (CPGs) have become increasingly popular, and the methodology to develop guidelines has evolved enormously. However, little attention has been given to the updating process, in contrast to the appraisal of the available literature. We conducted an international survey to identify current practices in CPG updating and explored the need to standardize and improve the methods. METHODS: We developed a questionnaire (28 items) based on a review of the existing literature about guideline updating and expert comments. We carried out the survey between March and July 2009, and it was sent by email to 106 institutions: 69 members of the Guidelines International Network who declared that they developed CPGs; 30 institutions included in the U.S. National Guideline Clearinghouse database that published more than 20 CPGs; and 7 institutions selected by an expert committee. RESULTS: Forty-four institutions answered the questionnaire (42% response rate). In the final analysis, 39 completed questionnaires were included. Thirty-six institutions (92%) reported that they update their guidelines. Thirty-one institutions (86%) have a formal procedure for updating their guidelines, and 19 (53%) have a formal procedure for deciding when a guideline becomes out of date. Institutions describe the process as moderately rigorous (36%) or acknowledge that it could certainly be more rigorous (36%). Twenty-two institutions (61%) alert guideline users on their website when a guideline is older than three to five years or when there is a risk of being outdated. Twenty-five institutions (64%) support the concept of "living guidelines," which are continuously monitored and updated. Eighteen institutions (46%) have plans to design a protocol to improve their guideline-updating process, and 21 (54%) are willing to share resources with other organizations. CONCLUSIONS: Our study is the first to describe the process of updating CPGs among prominent guideline institutions across the world, providing a comprehensive picture of guideline updating. There is an urgent need to develop rigorous international standards for this process and to minimize duplication of effort internationally

Tratamiento conservador del cáncer de mama: valoración de los resultados

Introducción: La asociación de cirugía limitada y radioterapia es el tratamiento de elección para un gran número de mujeres con cáncer de mama; no obstante esta opción terapéutica va asociada a un número no despreciable de recidivas sobre la mama tratada (1-1,5% por año de seguimiento). Material y Métodos: Se analizan 641 casos de mujeres con cáncer de mama, tratados mediante cirugía conservadora de la mama y radioterapia y seguidos durante una media de 50 meses. La técnica consistió preferentemente en la practica de una Resección Segmentaria de mama con vaciamiento axilar, al menos de los niveles I y II (excepto en los CIS a partir de 1997), complementada con la administración de Radioterapia (45-50 Gy sobre la mama y una sobreimpresión de 15-20 Gy). Resultados: La edad media fue de 52.3 años, con extremos en 21 y 82 años El tamaño medio tumoral fue pT: 1,7 cm y el 63,1% de los casos correspondieron a tumores pT1. En 41 casos no se realizó vaciamiento axilar (35 CIS y 6 pT1mic). En 4 casos existió afectación puntual de bordes (componente intraductal) que fueron sometidos a sobreimpresión radioterápica con 20Gy. Tras un seguimiento medio de 50 meses, el 91,4% están libres de enfermedad y en 12 casos (1,9%) se desconocía su estado. Se han producido 13 recidivas (2%) a nivel mamario (2 de ellas en un cuadrante distinto). Conclusiones: El estado de los bordes de resección en un factor fundamental en la cirugía conservadora del cáncer de mama. La resección del tumor debe ser suficientemente amplia e incluir el segmento mamario asiento del tumor, para asegurar un alto índice de control local, sin comprometer el resultado cosmético. El estudio histológico de los bordes de resección permite reducir significativamente la necesidad de una segunda cirugía.Introduction: Conservative surgery combined with radiotherapy is an effective treatment in many cases of breast cancer. Nevertheless this therapy is associated with a not inconsiderable number of recurrences in the remaining breast after excision (1-1.5% recurrences per year of follow-up). Material and Methods: We reviewed 641 cases of breast cancer (age average was 52.3 years (21-82) and tumour size average 1.7 cm, 3% corresponded to pT1 tumours) treated with conservative surgery combined with radiotherapy, average follow-up of 50 months. The technique consisted of segmentectomy and at least level I-II axilary dissection (excluding in situ carcinoma diagnosed since 1997, in which lymphadenectomy was not performed). Adjuvant radiotherapy was also indicated (giving a dose of 45-50 Gy to the breast, and another 15-20 Gy dose was given to tumour size). Results: In 41 cases lymphadenectomy was not performed (35 cases of Tis, and 6 pTmic). In 4 cases, 20 Gy radiotherapy was administered to the tumour excision site because of in situ carcinoma disease in the margins. During follow-up of 50 months, 91.4% of the patients were disease- free; in 12 cases we are not informed of the present status. 13 recurrences (2%) have been found, two of which were in a different quadrant. Conclusions: The status of the surgical margins is an important factor in the practice of conservative surgery. Tumour excision must be broad enough and must include the whole segment in which the tumour is located to obtain local control of the disease, maintaining an acceptable cosmetic appearance. The intraoperative study of specimen margins permits the reduction of cases in which a second operation is needed

Attitudes and perceptions about clinical guidelines: a qualitative study with Spanish physicians

Estudio cuyo objetivo es la evaluación de las actitudes y percepciones los médicos españoles con relación las Guías de práctica clínica. Spanish physicians towards CGs

Perceptions and attitudes of clinicians in Spain toward clinical practice guidelines and grading systems: a protocol for a qualitative study and a national survey

BACKGROUND: Clinical practice guidelines (CPGs) have become a very popular tool for decision making in healthcare. While there is some evidence that CPGs improve outcomes, there are numerous factors that influence their acceptability and use by healthcare providers. While evidence of clinicians' knowledge, perceptions and attitudes toward CPGs is extensive, results are still disperse and not conclusive. Our study will evaluate these issues in a large and representative sample of clinicians in Spain. METHODS/DESIGN: A mixed-method design combining qualitative and quantitative research techniques will evaluate general practitioners (GPs) and hospital-based specialists in Spain with the objective of exploring attitudes and perceptions about CPGs and evidence grading systems. The project will consist of two phases: during the first phase, group discussions will be carried out to gain insight into perceptions and attitudes of the participants, and during the second phase, this information will be completed by means of a survey, reaching a greater number of clinicians. We will explore these issues in GPs and hospital-based practitioners, with or without previous experience in guideline development. DISCUSSION: Our study will identify and gain insight into the perceived problems and barriers of Spanish practitioners in relation to guideline knowledge and use. The study will also explore beliefs and attitudes of clinicians towards CPGs and evidence grading systems used to rate the quality of the evidence and the strength of recommendations. Our results will provide guidance to healthcare researchers and healthcare decision makers to improve the use of guidelines in Spain and elsewhere